It's a great honor to introduce Mwenke Shab, M-A-S-G, from Johns Hopkins, who will be speaking as part of a point-counterpoint, and he'll be presenting the malignant gastric outlet obstruction, EUS-GJ, as a preferred endoscopic therapy. Good afternoon. Thank you for inviting me. It's a pleasure to be here. So I'm talking on EUS-GJ. These are my disclosures. So why do we need EUS-GJ? For malignant gastric outlet obstruction, duodenal stenting is established. Surgical GJ is established. You know, duodenal stenting, the main issue with it is tissue ingrowth, and with improved survival in patients with pancreatic ovulary cancers, we see a lot of patients coming back with recurrent gastric outlet obstruction. You know, at tertiary centers, I think surgical GJ and malignant gastric outlet obstruction should not happen again due to significant morbidity. The advantages of EUS-GJ, similarly to the surgical GJ, it's a bypass procedure. So we are stenting away from the tumor, so we eliminate the risk of tumor ingrowth. As an endoscopic procedure, we're still providing patients with a minimally invasive option. So the different techniques, I go for a direct EUS-GJ, or freehand technique. So let's see how this is done. This is a patient with duodenal hematoma, so benign disease, but still same technique. So we see the dilated stomach, and we see the hematoma here. So we put a gastroscope just proximal to the obstruction. I like to use the channel of a gastroscope to inject about 500 cc's under pressure. So this is important. Rather than injecting through a small catheter, we can inject a big volume, and with the pressure itself, we distend the small bowel. You see how it looks like a pseudo-pseudocyst that's opposed to the stomach. I put blue dye within the fluid so that we first put an FNA needle, aspirate blue dye to make sure this is the genome and not the colon. And then we deploy the stent. I use a 20 millimeter stent. I don't dilate. I let it dilate by itself. And as soon as we see blue dye, we know that we are in the right place. Important to talk about the axis. You saw a short axis of the jejunum. So it's relatively, it can be challenging, but in instances where you get a long axis of the jejunum, you can tell that now going with an axis here, look how you throw. It's, you can do five, six centimeters. So this makes the procedure much less challenging. So what I do is I take a quick look. If I can get a long axis, I will go for that. If I can't get a long axis, I will go with a short axis technique. And so this, we've been doing this for a while. Todd Barron and myself published the first experience in the U.S. on 10 patients with excellent success. Over time, you know, the outcomes became better. Here we, retrospectively, we compared duodenal stenting to GJ. So these are the two procedures we do almost on a daily or weekly basis. And we can see that the main difference was with recurrent gastric outlet obstruction. Because the stent is away from the tumor, so recurrent gastric outlet obstruction is uncommon. It can happen with food impaction. That's why these patients have to be on a low residue diet. The risk of recurrent obstruction with duodenal stenting is high because of tumor ingrowth. And here we see the most common cause of obstruction in the duodenal stenting arm was tissue ingrowth in the gastrointestinal arm. It was just food impaction. And then we compared our outcome surgical GJ to endoscopic GJ. For the most part, they are equivalent. And what this tells you that an endoscopic GJ gives you a patency that's similar to a surgical anastomosis. So the main problem with USGJ, the way I see it, it's still technically challenging. So steep learning curve. Here we published this paper. We see it to be proficient, 25 cases. To master the technique, you need 40 cases. This is if you have expertise in interventional US. So a steep learning curve, and I think that's the main reason why it hasn't taken over. You know, in principles, logically, and with some studies we have, we see that's superior to duodenal stenting, but it's not ubiquitous. It's not everywhere because of the steep learning curve. And the main issue, the main problem with the technique is we can misdeploy stents, and it happens to everyone. Here, after 39 cases, we stopped seeing stent misdeployments. Stent misdeployment is not equivalent to surgery. And this is really important. Because if we are fearful of stent misdeployments, then we will never do USGJ. So this is a large study we published, 467 patients in GIE, and we offered a classification for misdeployments. The rate of misdeployment was 10%. The rate of the need for surgery for misdeployment was overall, for all patients, 1%. So 10% of the 10% need surgery. Overall, 1% risk of surgery. So very low for an advanced, difficult procedure that's still figuring things out. And we classified, so it's important to classify, because we can't lump everything together. The most common kind of deployment is the one flange in the stomach, but the deep flange is in the peritoneum. It never reached the jejunum. So simply remove the stent, put a couple of clips, and retry or do a duodenal stent. These patients will never need surgery. You know, here we can see some patients went for surgery, but this is basically the endoscopist freaked out, and, you know, they don't know that these patients can be managed conservatively. Type 2 is similar, but there's a hole, and there's an enteronomy. Many of these patients can be managed conservatively, where you put just insert an NG, NPO, antibiotics, and the enteronomy closed. But these patients, you need to consult your surgeon and frequent abdominal exam. If they have developed peritonitis, then they go for surgery. And I will show you how we can use notes or peritoneoscopy technique to salvage this. But this is less common. Type 3 is where the flange is in the peritoneum and not the flange in the jejunum. These patients need surgery. Inadvertent gastrocolostomy, if you're mistaken, if you place basically the flange in the colon instead of the stomach. So what you do in these cases, let the tract mature, give it a couple of weeks, then remove the axis, and then suture it. So I do two layers. I've had two patients referred for this, and we did two layers suturing with full-thickness sutures. And then that worked nicely. This is a video. Again, this is very, very uncommon. And we saw this with our initial experience, but very uncommon. This is type 2, where you have the one stent is one flange is in the stomach, and the second flange is in the peritoneum. Many of these patients, you know, if you can do this, the notes technique, is you manage these patients conservatively, consult surgery with frequent abdominal examination. So here, we were lucky that we were able to find the enteronomy. And basically, you cannulate it, put a new axis, open the flange, pull it back to the stomach, and deploy the second flange. For the sake of time, I'm going to go to my conclusion. USGJ is safe and effective for palliation of malignant gastric ulcer obstruction. Endoscopists should have expertise in interventional US. Technical challenges can be overcome with several endoscopic techniques and expertise. I do think USGJ is superior to duodenal stenting. Prospective trials are needed. We do have an RCT under an investigational device exemption with the FDA ongoing. And it's a single center right now, but we're expanding for this to be a multi-center international study. So probably in a couple of years, we'll have level one data. I think USGJ is likely equivalent to a surgical GJ. So this is a slide I always like to look at. For USGJ, we're still, it's an innovation, right? We're still here. Early adopters. So just few endoscopists doing it, we see good results. That's why many of us are enthusiastic about it, want to study it, want to do it more, because we see it. But the procedure is difficult. For this to take off, we need devices that will make the procedure easier. And I tell you, there are devices that will be available in the next probably couple of years that will make this procedure easier. If it's easier and the outcomes are better in terms of patency, I think it will take over. But we're still in the initial stages. But I think the future is bright for USGJ. Thank you for your attention.

endoscopic therapy

malignant gastric outlet obstruction

endoscopic ultrasound-guided gastrojejunostomy

EUS-GJ

minimally invasive procedure